病生病例讨论 英文版

PATIENT CASE

Patient’s Chief Complaints患者主诉

Provided by wife: “My husband’s very confused and he has been acting strangely. This morning, he couldn’t answer my questions and seemed not to recognize me. I think that his stomach has been swelling up 膨胀again, too. He stopped drinking four years ago, but his cirrhosis肝硬化 seems to be getting worse.” HPI (History of present illness)

S.G. is a 46 yo white male with a history of chronic慢性的alcoholism 酗酒and alcoholic cirrhosis.酒精性肝硬变 He was admitted to the hospital from the outpatient门诊病人 clinic诊所 with abdominal 腹部的swelling 肿胀and confusion. He has unintentionally 无意间gained 15 lbs 磅during the past four weeks. According to his wife, the patient has not been sleeping well for several weeks, has been feeling very lethargic（昏睡） for the past three days, can’t seem to remember appointments 约会lately, and, uncharacteristically,不典型地 has lost his temper with her several times in the last month. S.G.’s boss at work had also telephoned her last week concerned about his “unusual and violent behavior on the job.” PMH (Past medical history)

 Pneumonia 肺炎9 years ago that resolved 解决with antimicrobial

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抗菌的therapy 治疗

 Cirrhosis 肝硬化secondary to继发 heavy alcohol use大量饮酒 diagnosed诊断4 years ago with ultrasound超声波 and liver biopsy 活组织检查( micronodular小结的cirrhosis)

 H/O uncontrolled ascites腹水 and peripheral外围的 edema浮肿，水肿 (H/O: history of)

 H/O two upper 上部的，较高的GI升糖指数 hemorrhages出血 上消化道出血？from esophageal食管的 varices 静脉曲张  H/O anemia贫血

 H/O E. coli-induced大肠杆菌引起的 bacterial peritonitis 细菌性腹膜炎4 years ago

 H/O acute急性的 pancreatitis胰腺炎 secondary to alcohol abuse饮酒过度

 No history to suggest cardiac心脏的 or gallbladder 胆囊disease 翻译：没有心脏或者胆囊的疾病史

 No previous diagnosis诊断 of viral病毒的 or autoimmune 自身免疫的hepatitis肝炎

翻译：先前没有病毒性或者自身免疫性肝炎的诊断 SURG外科

 S/P appendectomy阑尾切除术 requiring blood transfusions 输血30 years ago

 S/P open-reduction开放复位internal内部的 fixation定影 of right

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femur大腿骨 secondary to继发 MVA摩托车车祸 5 years ago (SP: status post病后状态; MVA: motor vehicle accident) FH (Family history)

 Father died at age 52 from liver disease of unknown etiology病因 翻译：父亲由于不明原因的肝脏疾病在52岁时去世

 Mother had rheumatoid arthritis风湿性关节炎 and ulcerative colitis溃疡性结肠炎, died from massive stroke 严重中风at age 66  Maternal aunt姨母, age 71, with Graves disease Graves 病  Patient has no siblings兄弟姐妹 翻译：病人没有兄弟姐妹 SH (Social history)

 Educated through eighth grade 翻译：8年级毕业

 Department store men’s clothing manager and salesman, 17-year career

 Married for 19 years with 1 daughter, age 10 翻译：结婚19年了，有一个10岁的女儿

 H/O ethanol乙醇 abuse, quit 5 years ago following MVA, previously drank 3 cases箱 of beer/week×15 years

 H/O IVDA (heroin) and intranasal鼻内的 cocaine可卡因, quit 5years ago (IVDA: intravenous静脉的 drug abuse)

 Has smoked approximately 1/2 ppd for many years (ppd: packs包

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per day)

Meds (medications医疗护理)

 Propranolol心得安（用于治疗心律不齐，心绞痛等） 10 mg po TID (po: by mouth口服, TID: three times daily)

 Spironolactone螺内酯（一种利尿药） 50 mg po QD (QD: every day)  Furosemide 速尿灵20 mg po QD

 MVI 多种维生素滴注1 tablet药片 po QD每天

 Occasional偶尔的 ibuprofen布洛芬（抗炎，阵痛药） or acetaminophen（退热药） for headache

 Patient has H/O non-compliance 违反义务with his medications ALL(Allergy过敏症)

NKDA (no known drug allergies) ROS (review of systems)

 Increasing abdominal girth 胸围（周长）

 (－) complaints of abdominal pain, fever, chills,寒冷 nausea,呕吐 vomiting,呕吐 hematemesis咯血, tarry stools柏油样便, loss of appetite,食欲减退 cough,咳嗽 chest pain胸痛, SOB (shortness of breath), 呼吸急速lightheadedness,头昏眼花的 weakness, blood in the urine（尿）, 尿中带血diarrhea,痢疾 constipation,便秘 and dry mouth口干

Patient Case Question 1. Hematolysis 咯血and tarry stools拉黑便 are clinical 临床的signs of which serious potential complication 并发症of

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cirrhosis? Gen (general)

The patient is restless, mildly 适度地jaundiced,患黄疸病的 and disoriented紊乱的 to time, place, and people. He is slow to answer questions and his answers make little sense. He is ill-appearing but in no obvious distress痛苦. VS (Vital重要的 signs)

 BP 120/75, P 83 and regular ( supine仰卧的)  BP118/70, P 80 and regular( standing站立的)  RR 14 and unlabored平静的  T 98.8F orally口温37.1摄氏度  WT 171 1bs 体重77.6千克  HT 5 ft-7 in  SaO2 =97﹪ Skin

 Warm, dry, and well perfused 遍布with normal turgor肿胀  Mild jaundice轻微黄疸

 ( +) spider nevi on chest胸部有蜘蛛痣  (－)palmar erythema肝掌

 Several ecchymoses（瘀斑） on lower extremities肢端  Large “cobra” tattoo 眼镜蛇纹身on right upper arm右上臂 HEENT (head, eyes, ears, nose, throat)

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 (－)bruises淤青, masses,集中 and deformities畸形 on head  ( +) icteric sclera巩膜黄染

 Pupils 瞳孔at 3 mm and reactive to light光反应灵敏  EOMI (extra-ocular眼睛的 movement intact完好无缺的)  Funduscopic exam 眼底镜检查WNL (WNL: within normal limits)

 TMs clear and intact 未损伤的(tympanic membrane鼓膜)鼓膜完好无损，听力清晰

 O/P pink, clear, and moist潮湿的 without erythema红斑 or lesions伤口

Neck/LN (lymph nodes淋巴结)  Supple柔软的

 (－) JVD (jugular venous颈静脉 detension轻松)  (－) goiter, thyroid nodules, carotid bruits, and adenopathy Chest

 Lungs CTA bilaterally without wheezes or crackles (CTA: clear to auscultation听诊)

 Diaphragmatic excursions WNL  Good air exchange  ( +) gynecomastia Heart

 RRR (regular rate and rhythm)

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 Normal S1 and S2 with no S3 or S4  No m/r/g heard (m/r/g: murmur/rub/gallop) Abd (abdomen腹部)

 Moderately distended, firm, and slightly tender  ( +) prominent veins observed around umbilicus  ( +) HSM (hepatosplenomegaly)  Active BS (bowel sounds)

 (－) guarding, rebound tenderness, palpable masses, and aortic, iliac, and renal bruits Genit/Rect (genitalia/rectum)  Heme-negative stool

 Penis normal, testicles moderately atrophic but without masses  Normal sphincter tone  ( +) hemorrhoids

 Prostate may be slightly enlarged but (－)for nodules and tenderness

MS/Ext (mental status/extremities)  No clubbing or edema

 Good peripheral pulses at 2+ throughout  Normal range of motion throughout Neuro

 CNs grossly intact

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 Brisk DTRs at 2+ (DTR: deep tendon response)  Slight asterixis noted  Strength is equal bilaterally  Confused and disoriented  Negative Babinski  Sensory grossly intact

Patient Case Question 2. Identify a minimum of 15 clinical signs and symptoms that are consistent with a diagnosis of cirrhosis. Laboratory Blood Test Results See Patient Case Table 18.1

Patient Case Table 18.1Laboratory Blood Test Results Na 135meq/L K 3.5 meq/L Cl 101 meq/L HCO3 25 meq/L BUN 12 mg/dL Cr 0.6 mg/dL Glu, fasting 90 mg/dL Hb 14.0g/dL Hct 39.7% MCV 90fL Plt 34,500/mm3 WBC 4,700/mm3 PT 15.6sec PTT 45.1 sec NH3 250ug/dL AST 107IU/L ALT 86 IU/L Alk Phos 224 IU/L Bilirubin 2.4 mg/dL Protein 6.6g/dL Alb 2.7 g/dL Ca 8.5mg/dL Mg 1.7 mg/dL AFP 90ng/mL HBsAg (-) HIV (-) Anti-HCV (+) HCV RNA 2.8million/mL ANA (-) Fe 75ug/dL Ferritin 200ng/mL Transferrin saturation 38% Ceruloplasmin 37mg/dL AFP: -fetoprotein (normal 0-15 ng/mL), ANA: antinuclear antibody, MCV: mean corpuscular volume, NH3 (normal 18-60 g/mL)

Patient Case Question 3. Is the patient anemic 贫血at this time and, if so, is the anemia normocytic正常红细胞性贫血microcytic小红细胞性贫血or macrocytic巨细胞性贫血?

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Patient Case Question 4. What is the most significant abnormality变态 that this patient’s CBC (completed blood count总红细胞数) has revealed显示?

Patient Case Question 5. Based on the laboratory data, why has this patient’s cirrhosis肝硬化 shown a sudden and unexpected progression上升?

Patient Case Question 6. Identify鉴定 four risk factors that may have contributed to导致 this patient’s current condition.

Patient Case Question 7. Why can bacterial peritonitis 细菌性腹膜炎be ruled out as a current potential diagnosis潜在的诊断?

Patient Case Question 8. What justification理由 might the patient’s primary health care provider have for conducting an ANA test?

Patient Case Question 9. Why can hemochromatosis血色沉着病 be ruled out as a contributing factor to this patient’s condition?

Patient Case Question 10. Why can Wilson disease be ruled out as a contributing factor to this patient’s condition?

Patient Case Question 11. Why can autoimmune hepatitis自身免疫性肝炎 and primary biliary cirrhosis原发性胆汁性肝硬化 be ruled out as contributing factors to this patient’s condition?

Patient Case Question 12. Is there any evidence that this patient is at high risk for osteoporosis骨质疏松症?

Patient Case Question 13. Identify two abnormal laboratory tests that

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are consistent with符合 ascites腹水.

Patient Case Question 14. Which single laboratory test strongly suggests that the patient has developed hepatic encephalopathy肝性脑病? Patient Case Question 15. How would you grade this patient’s encephalopathy脑病?

Patient Case Question 16. What is this patient’s CTP score?

Patient Case Question 17. What is the probability that this patient will live for one year?

Patient Case Question 18. Does this patient have any signs of dehydration 脱水or hepatorenal syndrome肝肾综合征?

Patient Case Question 19. The patient’s primary care provider has decided to conduct extensive大量的 clinical 门诊的studies for the diagnosis 诊断of liver cancer. Which single abnormal laboratory value 评价has raised a concern that hepatocellular carcinoma肝细胞癌 may have developed?

问题1：咯血和柏油样便是肝硬化哪一种严重的潜在并发症的临床症状？ 问题2：至少找出15个肝硬化的临床症状和体征。 问题3：这次患者有贫血吗？如果有，那么是正常红细胞性贫血，还是小细胞性或者大细胞性呢？ 问题4：这个病人的全血细胞计数说明了哪个最显著的异常问题？ 问题5：根据实验室检验的数据，为什么这个病人的肝硬化出现了急性和意外的恶化？ 问题6：说出4个可能会导致病人出现现在的症状的风险因素。 问题7：为什么细菌性腹膜炎不被考虑为当前潜在的诊断？ 问题8：病人的初级保健医护人员有什么理由让病人去做抗核抗体测试？ 问题9：作为病人病情的影响因素，为什么血色沉着病可以被排除？ 问题10：作为病人病情的影响因素，为什么Wilson病（肝豆状核变形）可以被排除？ 问题11：作为病人病情的影响因素，为什么自身免疫性肝炎和原发性胆汁性肝硬化可以被排除？ 问题12：是否有任何证据表明，这名病人存在患骨质疏松症的高风险？ 10

问题13：说出2个与腹部积水相关的异常的化验结果。 问题14：哪一个实验数据能强有力地证明病人已经患有肝性脑病？ 问题15：你将如何给病人的脑病分等级？ 问题16：这个病人的CTP评分是什么？ 问题17：这个病人能活一年的概率是多少？ 问题18：这个病人是否有脱水和肝肾综合征的任何迹象？ 问题19：这个病人的初级保健提供者已经打算为肝癌的诊断进行广泛的临床研究。哪一个化验的异常值表明肝细胞癌已经扩散？

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